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Houston Soccer for Success 2025-2026 Enrollment Form
Player Information
*
1.
Site Name
(Required.)
Alief Community Park (West Houston; Tuesdays & Thursdays)
Herman Brown Park (East/South Houston; Monday & Wednesdays)
Keith-Wise Park (North/Central Houston; Mondays & Wednesdays)
Mason Park (South East Houston; Mondays & Wednesdays)
Milby Park (South East Houston; Tuesdays & Thursdays)
Moody Park (North/Central Houston; Tuesdays & Thursdays)
*
2.
Player First Name
(Required.)
*
3.
Player Last Name
(Required.)
4.
Player Date of Birth (MM/DD/YYYY)
*
5.
Grade
(Required.)
K
1
2
3
4
5
6
7
8
*
6.
Has your child participated in Soccer for Success before?
(Required.)
Yes
No
*
7.
Does your child receive free/reduced price lunch at school during the school year?
(Required.)
Yes
No
*
8.
Gender
(Required.)
Male
Female
Prefer not to answer
*
9.
Ethnicity
(Required.)
African-American
American-Indian/Native Alaskan
Asian
Caucasian
Haitian
Hispanic/Latino
Pacific Islander
Other (please specify)
*
10.
School Name
(Required.)
*
11.
Jersey Size
(Required.)
YXS
YS
YM
YL
YXL
AM
AL
AXL
*
12.
Parent/Guardian Information
(Required.)
Name
Address
City
State
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP Code
Email Address
Phone Number
*
13.
Relationship to Child
(Required.)
Parent
Legal Guardian
Foster Parent
Grandparent
Sibling
Other Relative
*
14.
Are you interested in being a volunteer?
(Required.)
Yes
No
*
15.
Emergency Contact (Other than Parent/Guardian)
(Required.)
Name
Relationship to Child
Phone
16.
Secondary Emergency Contact (Optional)
Name
Relationship to Child
Phone
*
17.
I, the undersigned, understand that participation in the U.S. Soccer Foundation’s Soccer for Success
program (“Soccer for Success”) involves certain inherent risks of injury, despite all safety precautions
taken by the U.S. Soccer Foundation and operators. Therefore, as parent and/or guardian, I will assume
all risks, injury, sickness or illness, including communicable disease, for my child(ren) that may occur
during the participation in any activities or use of facilities associated with the Soccer for Success
program. In the event that my child(ren) need medical treatment due to accident or injury or natural
causes while registered and participating in the Soccer for Success program, I authorize the U.S. Soccer
Foundation staff and operators to take whatever action is necessary to care for my child(ren). I hereby
give permission to the U.S. Soccer Foundation staff and operators to use their best judgment in
arranging for my child(ren)’s emergency medical treatment in addition to contacting me to the best of
their ability. I certify that my child(ren) is/are fully covered by medical insurance and that I am fully
responsible for all costs incurred due to medical or dental treatment as deemed necessary by the U.S.
Soccer Foundation staff and operators.
By signing this form, I acknowledge that I am aware of the potential risks of participation in any activities
or use of facilities associated with the Soccer for Success program, and in no way hold the U.S. Soccer
Foundation, its respective parent, its subsidiaries or affiliates, or their respective management, agents,
employees, directors, officers, sponsoring agencies, volunteers or the facility or its operators, coaches,
officials, or advertisers, (Individually and Collectively, the “Released Parties”), liable for any injury that
my child(ren) may sustain. I, FOR MYSELF, MY SPOUSE AND MY CHILD(REN), DO RELEASE, ABSOLVE,
INDEMNIFY, AND HOLD THE RELEASED PARTIES HARMLESS AGAINST ANY CLAIMS OF INJURY OR
DEATH TO MY CHILD(REN) IN CONNECTION WITH ANY AND ALL OF THE ACTIVITIES MENTIONED.
Additionally, as the child(ren)’s parent/guardian, I acknowledge that my child(ren) may participate in the
Soccer for Success program via regular, virtual interactions with adults affiliated with the program
operator. I, FOR MYSELF, MY SPOUSE AND MY CHILD(REN), DO FURTHER RELEASE, ABSOLVE,
INDEMNIFY, AND HOLD THE RELEASED PARTIES HARMLESS AGAINST ANY CLAIMS OF INJURY OR
DEATH TO MY CHILD(REN) IN CONNECTION SPECIFICALLY WITH VIRTUAL INTERACTIVE
PROGRAMMING.
Finally, as the child(ren)’s parent/guardian, I hereby grant a license to the U.S. Soccer Foundation, and
their agents, including any advertising agencies, to use and to license others to use the child(ren)’s
name, recorded voice, image, picture or likeness in any live or recorded audio, video or photographic
display or other transmission for purposes of promotion and publicity in connection with the Soccer for
Success program and any future U.S. Soccer Foundation events or programs and hereby waive any rights
of compensation or ownership thereto.
I HAVE READ, AND I UNDERSTAND, AND I VOLUNTARILY SIGN, THIS MEDICAL
RELEASE/WAIVER/INDEMNITY AGREEMENT AND MODEL RELEASE AND AUTHORIZATION TO
VIDEO/PHOTOGRAPH.
(Required.)
Agree
*
18.
Parent/Legal Guardian Signature
(Required.)
